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Martin, Randy NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Randy Douglas Martin Male Date of Death Age If Veteran of U.S. Armed Forces, December 12,2013 59 War or Dates F. Place of Death Hospital, Institution or 2 City, Town or Village Lake Placid Street Address 41 Colden Ave. Ip Manner of Death X Natural Cause [ 'Accident Homicide Suicide Undetermined Pending tiCircumstances Investigation iu C Medical Certifier Name Title Francis W.Whitelaw Coroner Address 60 Maple Lane,Bloomingdale,NY 12913 Death Certificate Filed District Number Register Number City, Town or Village 1523 1523 /3 ❑Burial Date Cemetery or Crematory Entombment December 19,2013 Pine View Crematory Address ©Cremation 21 Quaker Rd.,Queensbury,NY 12804 Date Place Removed ORemoval and/or Held and/or Address E" Hold tn O Date Point of coTransportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address ri Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Clark,Inc. 01075 Address 2310 Saranac Ave.,Lake Placid,NY 12946 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above g Address Ir tu a. Permission is hereby granted to dispose of the human rem"s des bed ove as indicated. Date Issued 12-14-2013 Registrar of Vital Statistics _gfr..4a 'ie., (signature District Number 1523 Place Village of Lake Placid I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: iti Date of Disposition l -ao--('3 Place of Disposition Zdito.. Ci-vir,,-- W (address) Cl) re (section) (lot umber) (grave number) p Name of Sexton or Person in harge of P mises j slumber) p�,,,,i}- Wn (p se print) Signature c/� Title lecj►7�j f (over) DOH-1555 (02/2004)